Journal of Global Infectious DiseasesOfficial Publishing of INDUSEM and OPUS 12 Foundation, Inc. Users online:410  
Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size     
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
 


 
   Table of Contents     
PICTORIAL EDUCATION  
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 160-161
Spinal mucormycosis


Department of Spine, Wockhardt Hospitals, Mumbai Central, Maharashtra, India

Click here for correspondence address and email

Date of Web Publication12-Dec-2017
 

   Abstract 


Spinal mucormycosis is a rare and fatal condition. High degree of suspicion is required for early diagnosis and treatment.

Keywords: Mucormycosis, mortality, spinal

How to cite this article:
Shah K, Nene A. Spinal mucormycosis. J Global Infect Dis 2017;9:160-1

How to cite this URL:
Shah K, Nene A. Spinal mucormycosis. J Global Infect Dis [serial online] 2017 [cited 2019 Oct 15];9:160-1. Available from: http://www.jgid.org/text.asp?2017/9/4/160/220404




We report a case of a 54-year-old male who presented to us with progressive mechanical low back pain and right lower limb radiation since 3 weeks. There was rest pain and no constitutional symptoms. He was a known case of cryptogenic liver cirrhosis with portal hypertension and pancytopenia (hemoglobin, 8 g/dL; total leukocyte count, 3500/μL [neutrophils - 450/μL]; and platelet count, 90,000/μL). On examination, there was no neurodeficit, and spinal movements were painful.

Magnetic resonance imaging (MRI) (plain and contrast) was done as shown in [Figure 1] and [Figure 2]. Diagnosis of infective spondylodiscitis was made with the following possibilities: (1) tuberculosis (TB), (2) pyogenic vertebral osteomyelitis, (3) fungal infection, for example, aspergillosis, cryptococcal infection, and mucormycosis, and (4) unusual infection, for example,  Salmonella More Details spondylitis and  Brucellosis More Details. Radiological features in our case showed hyperintense T2 image and hypointense T1 image on plain MRI. Contrast MRI shows no disc enhancement with hyperintense signals in body. These findings are consistent with similar cases reported in literature.[1],[2] Although the disc space is preserved in TB in early stages, it is associated with gross vertebral body destruction and large abscess collection with disc space destruction in later stages. Clinically, TB has more indolent course.[3] Pyogenic spondylodiscitis has aggressive course and characterized by disc space destruction along with adjacent body and no skip lesions.[4] The hallmark of mucormycosis infection is angioinvasion and gross destruction of localized tissues. It has very aggressive course of progression and commonly seen with immunocompromised patients. Spinal involvement shows disc space sparing with localized abscess and vertebral body destruction.[1],[2]
Figure 1: Plain magnetic resonance imaging. (a) T2-weighted sagittal image showing hyperintense signal in L3 and L4 vertebra bodies with paradiscal erosions (arrow shown). (b) T2-weighted axial image with anterior soft tissue collection seen (arrow shown). (c) T1-weighted sagittal image showing hypointense signals from L3 and L4 vertebral bodies. (d) T1-weighted axial image with anterior soft tissue collection

Click here to view
Figure 2: Contrast magnetic resonance imaging. (a) T2-weighted image sagittal image showing L3 and L4 vertebral body enhancement without disc enhancement (arrow shown). (b) T2-weighted axial image through disc space showing no enhancement of disc space and peripheral soft tissue enhancement (arrow shown). (c) Coronal image showing hyperintense L3 and L4 vertebral bodies and no enhancement of psoas muscle. (d) T1-weighted sagittal image showing enhancement of L3 and L4 vertebral bodies

Click here to view


Computed tomography-guided biopsy was done to confirm the diagnosis. Histopathology report suggested mucormycosis. The primary aims of the treatment are early diagnosis, reversing of the risk factors, debridement of lesion, and instituting appropriate antifungals. Amphotericin B is the drug of choice; however, it is nephrotoxic. Surgical debridement is recommended to decrease infection load;[5] however, it is not always possible because of poor medical fitness of the patient. Chen et al. showed successful outcome after repeated spinal debridement of lesion.[1] In our case, because of medical reasons (cryptogenic liver cirrhosis with portal hypertension and pancytopenia), we could not perform surgery and liposomal amphotericin B 5 mg/kg/day was started in consultation with infectious disease specialist; however, the patient did not respond well clinically, the symptoms were persistent, and white blood cells count did not improve. He developed acute respiratory distress secondary to septicemia due to mucormycosis infection and succumbed to death at 2 weeks.

Spinal affection in mucormycosis is described scarcely in literature. Clinical presentation can range from pain and disability to neurological involvement. Neurological involvement can be due to filamentous infiltration of spinal vasculature leading to infarction. De Pasqual et al.[6] reported a case of pulmonary mucormycosis spreading to dorsal spine causing acute paraplegia. Laminectomy was performed and antifungal treatment was started. Scheduled lobectomy could not be performed due to altered clinical condition. The patient did not respond to medical management and eventually died. Machida et al.[7] reported a case of myelodysplastic syndrome with subacute myelopathy not responding to local irradiation. The patient died of pneumonia. Postmortem examination suggested spinal infarction due to fungal infiltration of anterior spinal artery. Hadgaonkar et al.[2] reported a case of isolated spinal mucormycosis presented with pain and disability, and due to medical comorbidities, surgical management was not performed and the patient did not respond to antifungals, eventually succumbed to death.

The possibility of unusual and atypical infection should always be kept in mind, especially in immunocompromised patients. This is particularly important in developing countries where TB is highly endemic, and empirical chemotherapy is started.[8] We recommend biopsy in every case of infective spondylodiscitis for starting correct therapy and prognosticating the fate of disease. Spinal mucormycosis is extremely rare and fatal with high rate of mortality; therefore, imaging findings should be borne in mind to prevent delay in treatment and predict prognosis.[1],[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chen F, Lü G, Kang Y, Ma Z, Lu C, Wang B, et al. Mucormycosis spondylodiscitis after lumbar disc puncture. Eur Spine J 2006;15:370-6.  Back to cited text no. 1
    
2.
Hadgaonkar S, Shah K, Bhojraj S, Nene A, Shyam A. Isolated mucormycotic spondylodiscitis of lumbar spine – A rare case report. J Orthop Case Rep 2015;5:55-7.  Back to cited text no. 2
[PUBMED]    
3.
Rivas-Garcia A, Sarria-Estrada S, Torrents-Odin C, Casas-Gomila L, Franquet E. Imaging findings of Pott's disease. Eur Spine J 2013;22 Suppl 4:567-78.  Back to cited text no. 3
[PUBMED]    
4.
Diehn FE. Imaging of spine infection. Radiol Clin North Am 2012;50:777-98.  Back to cited text no. 4
[PUBMED]    
5.
Spellberg B, Ibrahim AS. Recent advances in the treatment of mucormycosis. Curr Infect Dis Rep 2010;12:423-9.  Back to cited text no. 5
[PUBMED]    
6.
De Pasqual A, Deprez M, Ghaye B, Frère P, Kaschten B, Hayette MP, et al. Invasive pulmonary mucormycosis with invasion of the thoracic spine in a patient with myelodysplastic syndrome. Rev Med Liege 2008;63:702-6.  Back to cited text no. 6
    
7.
Machida U, Kami M, Uozaki H, Makimura K, Yamaguchi H, Hirai H. Subacute spinal cord infarction due to zygomycotic thrombosis in a patient with myelodysplastic syndrome. Haematologica 2000;85:1004-6.  Back to cited text no. 7
[PUBMED]    
8.
Jain AK. Tuberculosis of the spine: A fresh look at an old disease. J Bone Joint Surg Br 2010;92:905-13.  Back to cited text no. 8
[PUBMED]    

Top
Correspondence Address:
Kunal Shah
‘We Are Spine' centre.Aarav polyclinic, 10-Excel Arcade, Opposite Telephone exchange, Ghatkopar West, Mumbai - 400 086, Maharastra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgid.jgid_107_16

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    References
    Article Figures

 Article Access Statistics
    Viewed1094    
    Printed18    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal

Sitemap | What's New | Feedback | Copyright and Disclaimer | Contact Us
2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008